Onychocryptosis

On the list of medical conditions I did not want to get, having an ingrown toe nail is right up there with cancer and diabetes for me. The thought of having to numb my toe so that a piece of nail that was jabbing my skin could be removed terrified me. Unfortunately, that is exactly what happened.

First, a little bit of historical background. My toenail on my right big toe has been damaged for a decade. I don't remember kicking anything or dropping anything on the toe. I was at a concert at Deer Creek in the lawn, which is an incline so that as you get further away from the stage you can still see. I think standing on a hill for a prolonged period of time was enough to cause some damage to my nail, because the next day the nail was black as if it had blood pooled underneath.

For years I lived with a nail that was thick and discolored but never caused pain. It was unsightly, but otherwise wasn't causing any problems. That changed this summer when it became ingrown. I fought with it for about six weeks. I would do occasional soaks along with every other day nail cuts, trying to remove the jagged nail from my skin. I was chasing my tail, as it would improve for a day or two but would soon return to being uncomfortable. One day, it started hurting to the point that I was limping around the house. I was tired of dealing with it and so scheduled an appointment to have it taken care of.

The procedure was not nearly as bad as I had imagined. Anesthetizing the toe was mildly uncomfortable, but after that I couldn't feel anything. Essentially the discomfort resolved after the procedure. I had some minor sensations in the toe for about 5 days after the procedure, but those have since resolved and I have only had minor, intermittent symptoms since. 

Social Distancing

It's been a little over a month since we were told to "hunker down" and social distance.  Life has dramatically changed.  I'm mostly working from home.  Social locations are closed.  Common items like toilet paper have been difficult to find in stores.  And while there has been some preliminary discussion about slowly re-opening society, the longer this goes on the more likely it seems like life may never be "normal" again.  More to come on that I suppose, but there are talks of this lasting months or even oscillating in recurrence for years, much like how flu returns every year.  No question there has been a lot of negative consequences of this virus.  It is easy to focus on the negative, and I find myself doing so from time to time.  However, I want to focus on the positive because I think some good is going to come from this experience.  As time allows, I plan on doing a series of posts where I focus on positive changes that have occurred in my life because of this virus.  Some changes are small, others are potentially large.

Today I want to focus on a small change that may have big health benefits.  I was supposed to have a dental appointment sometime this spring and of course it has been cancelled.  It is somewhat normal for my teeth to feel like they are due for a good cleaning around the time of my dentist appointment.  I mentioned this to Sarah and she recommended that we both get electric toothbrushes.  My dental team has been recommending this for years but I never pulled the trigger.  However, now that I can't see my dentist as easily I decided it was time.  I bought a middle of the road brush from a price perspective and have used it a couple of times now.  I can say that I notice an improvement in how my mouth and teeth feel after brushing when using the electronic brush versus a traditional brush.  I'm hoping my overall dental health improves and my dental team notices the next time I get a check-up.  For now, I'm enjoying cleaner teeth!

Welcome To Virtual Reality

Practicing social distancing has become the new normal in an effort to decrease spread of the corona virus.  One of the interesting consequences of social distancing is the rise of meeting virtually.  We are seeing very few patients in the clinic.  Our appointments are almost exclusively done over telephone or video.  While some health systems have mature video visit infrastructure already setup, most don't leaving those systems scrambling to figure out how to deliver video visits to patients.  The urgency of the situation has greatly increased the speed at which these problems are being solved.  As we begin to offer people virtual visits and their acceptance increases, it will be interesting to see if this becomes a new normal in terms of delivering healthcare, and to what extent.

The other area where virtual meetings have increased is sports, specifically racing.  E-racing series were already a thing, and iRacing has been huge for years.  However, the forced shutdown of sports was a perfect catalyst to increase E-sports presence for the mainstream, and racing has jumped on board without hesitation.  NASCAR had an iRace last weekend at Homestead that attracted nearly a million viewers and Indycar is set to debut their virtual series today.  

Meeting virtually has been an option for years but the COVID-19 situation has forced virtual meetings to become more mainstream.  It will be interesting to see how much of this continues to occur once the pandemic calms down.  I can now reject your reality, and substitute my own.

Covid-19

Shockingly, Sinclair media and Youtube TV came to an agreement for the Fox regional sports networks.  I didn't think there was anyway that would happen considering previous deals with seemingly all other tv providers had not been renewed.  A few channels on the coasts were left out, but luckily I live in the middle of the country so we should continue to get the Pacers as well as Fox Sports Midwest.

This past week the Covid-19 virus released havoc on our society, altering work schedules and school schedules, as well as sports schedules.  With essentially all sports either delayed or cancelled, for the moment there is absolutely no benefit of having the regional sports networks.  I bring all of this up because with sports disappearing for the time being, it is amazing how open my evening and weekend schedules have become.  Sports play a central role in my personal schedule, and the absence of events leaves a huge void in my evenings.    I am going to try to take the opportunity to catch up on some TV I've been hoarding on the DVR or maybe pick up video games again.  While this is an opportunity to watch TV, like everyone else, I am looking forward to the virus slowing down and returning to normalcy.  I've never experienced anything quite like this before.

Physicals That Aren't Physicals and Pharmacists Who Perform Physicals

There is this thing that exists called a medicare wellness visit or medicare wellness exam that isn't really an exam at all.  Once people turn 65 years and qualify for medicare, they get this booklet that informs them of what benefits they have with their new insurance.  Included in these benefits is an annual wellness exam.  The trouble is this "wellness exam" isn't an exam at all.  It's a series of question designed to assess one's health risks, including fall risk.  So now you have people who have been going to the doctor their entire lives, getting annual exams, being told that their wellness exam does not actually involve an exam.  Imagine the confusion.  It's unfortunate nomenclature.  In fact, the "exam" doesn't even have to be performed by a physician (or a nurse practitioner or physician assistant for that matter).

I was sitting in a meeting earlier this week and we were discussing these exams and it was mentioned that one of the clinics now has a pharmacist who would be performing the exams, managing patient's medicines, etc.  I thought we already had a position for people who did such things - it's called a doctor.  What in the world are we doing?!?

On a completely different topic, I did possibly the nerdiest thing I have ever done in my life over this past weekend.  Sarah and I went to listen to an orchestra play music from the Legend of Zelda gaming series.  I've always been a big fan of the games and I absolutely love the music so it was really cool to get to hear it performed by a live orchestra.

Epically Awful

At the beginning of November we got a new computer system in our office called Epic.  This new system affects all aspects of our office, from patient check-in to communication with patients to office visits, as the front office, nurses, and doctors use the new system.  Everything that goes on in our office goes through the new system.  Needless to say most people were nervous about this change as it was undoubtedly going to change workflow and how people do their jobs.  I, on the other hand, was pretty laid back about the change because I use Epic in one of my other jobs and thus am used to the system.  I was wrong about being laid back.  I should have been nervous.  The month of November is almost finished and I haven't had one good day at work this entire month.

It's difficult to describe in words what this change does to an office.  You almost have to witness it in person.  Everything is delayed.  Checking patients in, getting them to the rooms, doing routine tasks are delayed.  Refilling medicines and placing orders for labs or images get dropped or lost and patients call back wondering what happened.  Even filtering messages from phone calls around the office is a challenge.  For the first time in my career I have began telling people that we don't have time to address all of their concerns and that they will need to come back.  For the first time in my career I have not looked forward to going to work.  Last week, we were running over an hour behind schedule and when someone told me they didn't think I was listening to them I snapped at them.  When you go to work for 3 straight weeks and everything you do is wrong or in question you can only take so much.  When you have to apologize again and again for delays it gets to be a bit much.

Things will get better as we all get used to the whole system.  In fact, things are already better now compared to when we first started.  But there is a larger issue here, one that is beyond the scope of this post.  I am concerned about the future of healthcare in this country.  It is increasingly complex to provide even the most simplest of care.  If the non-medical person saw what goes on behind the scenes (how much effort is needed) after the patient leaves the office to deliver their care I think most people would be shocked.  This coupled with increasing cost and higher demands to deliver top quality care in less amount of time I believe is an equation that can't be solved.  Time will tell I suppose.  In the meantime, I hope things with Epic improve sooner rather than later.  I can't handle too many more days of this.

A Prostate Exam? Really?!?

I randomly came across this story on Sports Illustrated tonight about a man who is planning on undergoing a prostate exam at a minor league baseball game to raise prostate cancer awareness.  This story is so off-base it irritates me.  First off, the man is 45 years old.  The recommended age to begin screening for prostate cancer in a white male at average risk is 50.  This point is minor.  The major flaw in this "promotion" is that the American Urological Association, the American College of Physicians, the American Academy of Family Physicians, and the various cancer societies recommend against prostate exam for screening for prostate cancer.  Instead, they recommend checking the prostate-specific antigen lab test (PSA) if screening is going to be performed or to not screen at all.  These types of "promotions" do nothing but confuse people and probably push agendas.

Why Pay For Performance Will Never Work In Health Care

There is this concept in medicine called "pay for performance" where they link a portion of a physician's salary to how well his/her patients are doing.  They typically look at some measurable value such as percentage of patients who have controlled blood pressure or controlled diabetes.  If you have enough patients who meet the measures, you get paid extra.  If you don't then you don't get paid extra.  It is a simple concept and I understand its origins (there are a lot of doctors out there doing goofy stuff).  It is already being used in other countries with mixed results.  It will never work in American health care and here is why.

• a non-controlled diabetic no-shows a follow up appointment to discuss better ways to improve sugar control
• a non-controlled diabetic admits to taking their medicne on average every other day because they "can't remember"
• a new patient with markedly elevated blood pressure says "I'm not going to take medicine" before we even discuss treatment options
• A patient refuses to take a medicine due to things they've read on the internet but is willing to take a supplement for the ailment

 These are just some examples from the past week of things that I've had to deal with.  In the example of the blood pressure patient, I explain the known poor health outcomes of having prolonged hypertension, document that we discussed it and that they were unwilling to take medicine at this time, and move on with life.  In a pay for performance environment, I would have done the exact same thing and then promptly sent him a letter discharging him from my practice.  Who could afford not to?  As a physician I am in a position to offer advice that is based on my knowledge and health studies.  I cannot force people to do anything.  What they do with the knowledge and suggestions I make is completely up to them.  There are too many people out there who will believe the internet or something their grandma says before they'll take my advice.  There is no way pay for performance will work.  There will be too many people without access to health care.

On a completely unrelated topic, today is Anna Kournikova's birthday.  I believe she is 33 years old today.  I don't hear much from Ms. Kournikova these days.  She has done a pretty good job of staying out of the limelight.  I was a huge fan back in the day when she played.

The Unfortunate Reality of Modern Medicine

The Onion is a spoof news website that writes sarcastic and funny stories that reflect today's society.  This story about physician ratings sadly is quite accurate about how today's physicians are rated.  I find it pretty sad that anymore doctors are rated not by what they know or how good they are at their job but instead by meaningless measures such as the one mentioned in this story.  I kid about the seriousness of this to an extent, but you'd be surprised (or maybe not) by how many patients I pick up from Google.  I guess my ratings are good, at least for now.

Communist Medicine

I recently got my flu vaccine for the year.  I had to sign a waiver saying that I agreed to get the flu shot.  Not that it really mattered if I signed the form.  If I refuse to get the shot I would likely lose my job.  Other healthcare workers who have refused the flu shot have been fired.  While I am not against the flu shot in general, I will say that I am against forcing people to receive it.  To my knowledge there is minimal (or no) evidence that mass immunizing a healthcare population reduces spread of the flu.  That alone is enough for me to question the requirement.  I won't even begin to get into the ethical principles of forcing people to inject substances into their bodies that they don't want.

Patients or patience?

I graduated from residency over a month ago and for various reasons that are both beyond the scope of this entry and boring to discuss, my first official day in my new clinic as a full time doctor was today.  There are a lot of perks to being a full time doc versus being in residency.  To name a few, I have a set schedule, I have my own office within my clinic with two computers and office supplies, a much quieter work environment, and so on and so forth.  In addition, graduating from an accredited residency program says that I have the skills necessary to be a competent doc.  I seem to have everything that I need to succeed, with one big exception: patients.  On my first day at my new clinic I only saw one patient, and technically it was another doctor’s patient who basically just needed a medicine refill.

I really didn’t anticipate being a real doctor would be like this.  I thought that as soon as I opened shop people would come.  Apparently my expectations were wrong.  Everyone I’ve talked to says it is normal to be slow when first starting and that things will pick up.  I hope they’re right.  Otherwise I am going to be a very bored real doctor.

Intelligent 'iKnife' diagnoses cancer midsurgery

This is just awesome.  I fear, however, that someday my job will be replaced by Watson and all of the other computers of the world...

Angelina Jolie's Mastectomy: What You Should Know

This is a good article summarizing situations where it is suggested that women get tested for BRCA mutations.  Angelina Jolie's prophylactic mastectomy and her decision to go public with her surgery places breast cancer in the public eye more than it already is.  It is a disease that is unfortunately quite common.  Knowing what to do in terms of screening and being safe can be confusing.  Based on the suggestions in the article, I would say that most women do not qualify for BRCA mutation screening.  It should be noted too that the overwhelming majority of breast cancers are sporadic cancers and do not have hereditary components.  This places most women in the category of annual or bi-annual screening with mammography starting at age 40.

Primary Care Treatment for UTI Could Save $2 Billion

I bring this article up because this exact topic just came up in our office on Friday and also because I find the amount of money that could be saved to be mind blowing.  Patients go to the ER for this kind of thing I believe mostly because of lack of access to care.  We had a patient who called in on Friday who wanted to know if we could call her in antibiotics because she thought she had a UTI.  She was told that she had to make an appointment to be seen.  It turns out that in an adult woman studies have shown that having certain symptoms is more sensitive and specific for UTI than a urine dipstick, so generally speaking there is no need to see the patient.  I think in most instances just calling in the antibiotic is perfectly fine.  It bypasses hurdles to getting adequate treatment and possible saves us $2 billion or more.  That is an incredible amount of money.

Study: Fish oil doesn't help prevent heart attacks

I think we have a pretty good idea that having chronic inflammation raises your risk of cardiovascular events.  Having elevated C-reactive protein has been shown to be associated with cardiovascular events.  However, taking various anti-inflammatory medicines, such as various fish oils, has not been shown to be beneficial in terms of reducing your risks of having a cardiovascular event.  That is why I never suggest people start taking them.  If the goal of taking such supplements is to protect yourself from having a heart attack, and there is no proof that taking them does so, why waste your money?  I don't tell people not to take them, I just don't get enthusiastic about suggesting them.

Let’s (Not) Get Physicals

I have heard arguments against annual physicals and tend to agree with them.  For the average, mostly healthy American without chronic disease I think most can go a few years in-between exams.  The overwhelming majority of screens occur at a minimum of three years and we (doctors) tend to get a lot of information during other visits (inevitably a cmp lab test will be drawn, for example, which shows blood sugars for diabetes and kidney function, among other things, for example).  Furthermore, there is no data that getting annual exams accomplishes anything.  A recent study out of Europe showed no mortality benefit for those people receiving annual exams versus those who didn't and instead only went to the doctor when there was a problem.  I can tell you that I have watched and performed many well child visits in kids who are in school where I was pretty certain nothing of medical significance was accomplished.

I think two exceptions to the rule are people with chronic medical conditions requiring prescription meds.  They should probably be seen at least once annually.  The other exception that I have to spreading out visits is that the annual exam is a good time to make sure a patient is up to date on their screening tests.  However, as I mentioned, most tests can go at least a few years before they need to be repeated.

I'd like to see the dentist's data and rational for requiring two visits per year for teeth.  At least for the rest of the body, it seems as if such frequent visits really isn't necessary.

Gut bugs are implicated in heart attacks and stroke

It really is interesting to watch as research continues to find new ways to assess risk factors for stroke and heart attack.  Maybe sometime in the near future we will be checking TMAO levels instead of cholesterol levels.

PSA test leads to further procedures, harms: study

The PSA test is the elephant in the room when it comes to men's health.  There are a lot of opinions on the topic and anecdotal stories but the evidence is pretty clear that for the majority of people the test does more harm than good.  This story is old news (see this release from the USPSTF from nearly a year ago) and because the evidence for the test is so low I do not routinely order this test.  The only time I do use it is if men experience LUTS or if a patient specifically requests the test.  If they do request the test, I will order it but we have a discussion on what we are going to do with the results if they are positive before I order the test.

Company recalls birth control batch containing extra placebos

I love the line from the company's vice president: "I looked at it and said, 'there could be unwanted pregnancies out there."  You think?  Turns out the most important pill of the pack to take (i.e. not miss) is the first one after the week of placebos.  Missing the first seven after the week of placebos will result in pregnancy for sure.

Should You Worry About Your Vitamin D Levels?

Along with the gluten-free diet, vitamin testing seems to be very popular as well.  Specifically, testing vitamin d levels.  A large portion of the population where I work seem to be deficient in vitamin d according to lab parameters.  When vitamin d levels are tested and are low then people are frequently put on supplementation.  I have seen doses as high as 50,000 IU once or twice per week.  In general, I agree with most of what this article says about vitamin D.  There have been some loose associations with vitamin d and heart disease and cancer, but nothing to my knowledge of substantial evidence.  Also, I don't know of any study showing morbidity or mortality benefit from vitamin d supplementation.  Until there is more clear cut evidence, I really think testing vitamin d and supplementing with large doses is benefiting the number on the lab page more than it is benefiting the patient.  More on this topic to come for sure in the future.